This issue of the Motherisk newsletter marks the launch of our fetal alcohol research group. Dubbed FACE (Fetal Alcohol Canadian Expertise) we believe it is the first invitation to all Canadian researchers studying the fetal burden of maternal drinking to share a similar agenda. As reflected in the activities of the Motherisk program that are highlighted in this newsletter, fetal alcohol research spans from molecular medicine to health economy, from metabolic etiologies to child neurodevelopment.

We believe that by collaborating
with colleagues throughout the country we can build on existing expertise
and resources, enhance the ability to secure research funding and develop
crucial new knowledge.

We may also have greater impact as
advocates when addressing the various levels of governments that must
deal with the tremendous burden of this life-long disability.

If you have or are aware of a Canadian
program directly or indirectly involved in fetal alcohol research, please
let us know. This invitation is open to researchers in all fields of medical
and social sciences.

Fetal alcohol syndrome and other
alcohol related effects are the most common preventable causes of mental
retardation and developmental delay. Only through top notch research can
we hope to find ways to prevent or manage it.

Gideon Koren, MD, FACMT, FRCPC
Director, The Motherisk Program

The Alcohol and Substance Use Helpline Update
Who is calling and what are they asking?

Q: I am pregnant and past my first trimester. Is it okay for me to drink
alcohol now? Q: I am breastfeeding my newborn and like to have wine with my dinner.Q: I didnít know that I was pregnant when I went to a party last week. I drank more than I usually would and now Iím worried about fetal alcohol syndrome.

What are the risks to my baby?
The Alcohol and Substance
Use Helpline has answered these and hundreds of similar questions. Operating
daily from 9:00 a.m. to 5:00 p.m. in each of Canadaís time zones, the
Motherisk Helpline hears from physicians, other health professionals and
women throughout Canada. Whenever possible, callers are referred to treatment
and support services in their home communities. Helpline counsellors also
arrange for FAS assessment at The Hospital for Sick Children. The objective
is to deliver evidence-based information to every caller and provide access
to follow-up services.

Calls to the toll-free Helpline have
increased steadily since its inception in 1998. As of July 28, 2000 Motherisk
counsellors have received over 7900 calls related to alcohol and the use
of cigarettes, cocaine, ecstasy and similar substances during pregnancy
and while breastfeeding. (1) This represents approximately 22% of all
calls to Motherisk in the same time period.

Most of the calls are from women
themselves, rather than from their healthcare providers. The women range
in age from 15 to 35 and older, and call Motherisk from all 10 provinces,
the Territories and the United States. Still best known here in Ontario,
the vast number of the calls are from within Ontario, with Alberta, British
Columbia, and Quebec in second, third and fourth places, respectively.

Alcohol related calls constitute
the second largest number of inquiries following calls about the effects
of nicotine. Other commom questions include those about marijuana, cocaine
and ecstasy use. The reason that nicotine arises so frequently is because
there is a correlation between smoking and the use of alcohol and other
recreational drugs. For example, a call concerning the use of cocaine
is likely to also reveal the use of nicotine, but not necessarily alcohol.
Also, women who drink socially may find it easier to discontinue drinking,
while women who smoke may find it harder to overcome the underlying dependence.

In order to raise awareness of the
service among healthcare workers and physicians, Motherisk staff has traveled
to regional meetings of the College of Family Physicians throughout Canada.
An increase of 45% in clinician calls and referrals over the past 6 months
may be attributable to this targeted promotional effort.

The Motherisk Alcohol and Substance
Use Helpline counsels hundreds of women each month on the risk of exposure
to alcohol and other substances during pregnancy and while breastfeeding.
Each conversation aims to meet individual needs. As a result, the length
of calls can range from 10 minutes to one hour, depending on the variety
of issues presented. Whenever possible, callers are linked to support
services and followed up to monitor their situations. There is every indication
that the demand for this sort of timely and authoritative counselling
will continue to rise. Our goal - to ensure that those who need help will
have reliable access to information and support. The Alcohol and Substance
Use Helpline is supported by the Brewers Association of Canada.

E. Ho, Motherisk
counsellor

Additional support for the Alcohol
Helpline is provided by a grant under Health Canadaís Population Health
Fund. The views expressed herein do not necessarily represent the official
policy of Health Canada.

Neurodevelopment of children exposed in Utero to maternal binge alcohol consumption - a prospective, controlled study

Binge drinking, defined as a minimum
of 5 drinks per single occasion, is a common form of alcohol consumption
among North American women. Thirty-seven percent of pregnant teens and
24 percent of other pregnant women have reported drinking more than 5
drinks per single occasion in the first trimester of pregnancy (1,2)
. Epidemiological data has shown an increased prevalence of binge drinking
in pregnant women from 0.7 percent in 1991 to 2.9 percent in 1995.(3)
The objectives of the Motherisk binge drinking study were to assess the
fetal risk of maternal binge drinking during early pregnancy and to evaluate
the specific effects of binge frequency. Our aim was to compare neurodevelopment
of children exposed to maternal binge drinking in utero with children
not exposed to known human teratogens.

The Women Included In The Study
The study group was comprised of women who called Motherisk about a binge
drinking episode that occurred before they knew they were pregnant. A
unique aspect of this prospective study is that the majority of the women
in the study group remembered the exact time and number of binge drinking
events.

The number of binges reported ranged
from 1 to 20 episodes. Sixty-seven percent of women reported 1 to 3 binges
with 5 to 6 drinks per binge. Eight percent reported 4 to 5 binges. Twenty-five
percent reported more than six binges, with 5 to 7 drinks per binge. Ninety-one
percent of women stopped drinking between 5 and 9 weeks of gestation,
while 4 women continued drinking up to 12 weeks.

The mothers were assessed for IQ,
as well as socio-economic status (SES), and were asked to answer a questionnaire
about family function. To reduce the significance of confounders, mothers
in the study group were matched to the comparison group for age, IQ, SES
and number of cigarettes smoked. The mothers from the study group were
not significantly different from the comparison group with regard to these
matching criteria.

The Children The study and comparison
groups each included 51 children and their mothers. Children were included
if their mothers reported binge drinking in the first trimester of pregnancy.
Children were excluded if their mothers were heavy drinkers, or drank
between binging events, or the child was exposed to known teratogens or
other conditions that would adversely affect fetal outcome.

Before pregnancy outcome was known
we collected information about maternal lifestyle, medical and obstetric
history. A postnatal assessment including maternal and perinatal history,
as well as the child's milestones, was first performed when the child
was 6 to 9 months old. When the children reached the age of approximately
17 months or older they were assessed with a wide range of age appropriate
neurobehavioral tests.

Neurodevelopment of children up to
36 months of age (n=26) was assessed with the Bayley Scales of Infant
Development ñ II, childrenís cognitive abilities were tested with McCarthy
Scales of Childrenís Ability (3 to 7 years of age, n=22), and the Wechsler
Intelligence Scale III (n=3) was applied to the older children. The childrenís
language was assessed with Reynell Developmental Language Scales.

Results Comparison statistics were followed by correlation and multivariate
analysis. The children exposed in utero to maternal binge drinking were
not different from the children of the matched comparison group in their
age and physical characteristics. Nor did the study and control children
differ with regard to Global IQ and Reynell language tests.

We also analyzed the neurobehavioral
outcome with regard to the number of binges, number of drinks per binge
and alcohol index, and again found no effect on cognitive abilities. Furthermore,
when we performed regression analysis using maternal IQ, SES, parent stress
measure, gestation age (GA), and maternal drinking as independent variables,
we found that the childrenís cognitive outcomes were not affected by any
of these independent variables.

Temperament Assessments
Differences did arise, however, with regard to three out of nine temperament
scales. Children exposed to more than six binges were rated higher in
approach, adaptability and distractibility. Table 1

Approach scores were significantly
higher among the study group children, indicating that these children
were more disinhibited. Our findings showed that the number of binges,
as well as the number of drinks per binge and alcohol index were significant
predictors of outgoing behavior. The children of women who engaged in
more binges were more willing to approach the unfamiliar. A similar pattern
was observed for adaptability with maternal stress also accounting for
a substantial proportion of the variance, reflecting poorer adaptability.
We also found that maternal stress contributed significantly to distractibility.
Table 2

We concluded that maternal binge
drinking in early gestation affects preschool and school age childrenís
behavior to a greater degree than cognitive function. Temperament is a
more sensitive measure of a childís behavior than cognitive measures.
Greater disinhibition may be a risk for future psychopathology and behavioral
problems.

Alcohol is the most
widely used human teratogen, yet the biochemical mechanism of teratogenesis
is not known (1). Fetal alcohol syndrome
(FAS) is the most severe of fetal alcohol related abnormalities which
may be seen in the children of women who drink heavily throughout pregnancy
(2). It is also the leading cause of
mental retardation.

As with any other drugs
of abuse, the ascertainment of gestational exposure to alcohol is critical
to the diagnosis of fetal alcohol related abnormalities.The most common
methods for detection of alcohol use rely on maternal reports. However,
it is widely recognized that maternal reports are likely to underestimate
the true amount of alcohol consumed.

The easiest way to identify
alcohol use is to measure it in blood, breath or urine, but this simple
test cannot distinguish between acute and chronic alcohol consumption.
Moreover, it has been shown not to detect "second hand drinking" by the
fetus.

In order to establish
a diagnosis of fetal alcohol related abnormalities, in utero exposure
to ethanol is best established by an objective biological marker for alcohol
or alcohol metabolites, such as acetaldehyde "seen" by the fetus. Stoler
et al used a combination of 4 maternal blood markers of alcohol use in
detecting alcohol-abusing pregnant women, yet many cases were missed.
(3) A direct test in the newborn would
potentially yield more direct information about the magnitude of true
gestational exposure to alcohol which in turn, could be used in the clinical
diagnosis of the child. Yet until recently there has been no objective
biological marker for the detection of long term in utero exposure to
alcohol.

Motheriskís search for
that objective bio-marker is based in part on studies in adult drinkers
showing that circulating ethanol is transesterified with fatty acids to
produce fatty acid ethyl esters (FAEE). Other recent studies have identified
FAEE in meconium (4). Presently it
is not known whether FAEE are formed mostly in the mother and cross the
placenta or whether they are formed in the fetus as well. Bearer et al
have shown that the placenta has the necessary enzyme to produce these
alcohol metabolites (5). Our in vitro
studies provide the first evidence that transesterification of ethanol
and fatty acids can occur in the meconium itself.

We are now embarking
on a large epidemiological study which will be instrumental in evaluating
the maternal-fetal pharmacokinetics of FAEE, and the relationship between
the patterns and amounts of alcohol consumed by the pregnant mother and
the accumulation of FAEE in meconium.

If confirmed by large
studies, FAEE may become the first neonatal biological marker for babies
at risk for alcohol-related birth defects.

In 1973 Jones and Smith1
put a name to the deleterious effects of alcohol on the developing embryo/fetus
and coined the term Fetal Alcohol Syndrome (FAS). Since then researchers
have sought to understand the mechanism leading to the fetotoxic effects
of maternal alcohol consumption. A number of mechanisms have been proposed
and possible contributions from more than one pathway suggests that alcohol
related birth defects (ARBD) may be a multifactorial manifestation. The
relative contribution of ethanol and its first proximate metabolite, acetaldehyde
(AcH), to the teratogenesis still is not known, but both have been illustrated
to be teratogens in animals (2-5).

We know that blood alcohol
concentration-time curves do not differ significantly betweenalcoholics
and non-alcoholics. (6,7) In contrast,
AcH levels may be variable and elevated in some alcoholics (8-11).
Some studies have been done to suggest that women who give birth to children
with ARBD have a trend towards higher AcH levels (12,13).
The high degree of variability in the clinical presentation of ARBD (only
about 4 % of alcoholic women produce children with FAS), may be explained
by the high degree of variability of AcH levels found in alcoholics, as
compared to low variability of ethanol concentrations. It may be then,
that alcoholics who produce high AcH levels are at risk of having an affected
child (14).

We also know that the
characteristic facial features present in those affected with the full-blown
syndrome are not unique to FAS. The presence of epicanthic folds, wide
nasal bridge, short nose, undefined philtrum, and thin upper lip are also
characteristic of pyruvate dehydrogenase (PDH) deficiency. PDH deficiency
is a mitochondrial disorder affecting energy metabolism (15).
The impaired ability to convert pyruvate to acetyl coenzyme A (CoA) that
occurs in PDH deficiency results in secondary lactic acidosis and thus
has a significant effect on fetal development. Because of the similarities
in the facial anomalies characteristic of FAS and PDH deficiency, and
the variability of AcH levels among alcoholics, we have hypothesized that
impairment of PDH occurs in the presence of AcH and contributes to the
pathogenesis of ARBD.

We have conducted kinetic
experiments with purified porcine heart PDH and showed that AcH inhibits
PDH. Parallel studies using ethanol instead of AcH as the potential inhibitor
showed no inhibition. Purified PDH complex incubated with [1,2-(14)
C]-AcH formed covalent adducts with proteins in the complex,
but such covalent binding was non-contributory to the observed inhibition.
Our results show that AcH impairs the activity of PDH. Since PDH levels
are low throughout development and do not reach adult levels until the
fetus reaches term, even a small degree of inhibition may have severe
effects (16).

Work is currently in
progress to document the effects of AcH on PDH in the fetal rat.

On September
8, 2000 Motherisk will host the Fetal Alcohol Syndrome Research Roundtable
at The Hospital for Sick Children where Canadian clinical and experimental
researchers will present their latest findings. It will be a day-long
discussion of the markers, mechanisms, and biologic effects of FAS, as
well as evidence-based research concerning FAS prevention, diagnosis and
intervention.The articles in this issue of the Motherisk Newsletter, along
with the following abstracts, describe much of the research to be discussed
at the September 8th Roundtable.

Background Alcohol Related Neurodevelopmental Disorder (ARND) describes children
whose neuropsychological development has been adversely affected by prenatal
alcohol exposure, and includes children who do not meet all the diagnostic
criteria for FAS. A major problem in diagnosing these children is that
the clinical phenotype of ARND without physical dysmorphology has not
been well-defined. This work represents the first systematic clinical
report on diagnosing ARND in Canada.

Methods
Fifty-two children aged 4-18 years were referred to a hospital-based outpatient
program in Toronto for a diagnostic assessment related to their prenatal
alcohol exposure. We first used widely accepted clinical methods which
were not pathognomonic. Subsequently, we took a novel approach by hypothesizing
a neuropsychological profile of assets and deficits which better characterized
the effects of prenatal alcohol exposure. We next determined the extent
to which each child's individual neuropsychological profile was consistent
with the proposed ARND profile. Statistical comparisons were made between
those children fitting the ARND profile and those who did not in order
to clarify which neuropsychological characteristics most significantly
differentiated the two groups.

Results
Fifty-seven percent (28 of 52) of the children who fulfilled our criteria
were assigned to the ARND group while the remainder were assigned to the
non-ARND group. While the two groups did not differ in physical presentation,
children in the ARND group were more likely to have repeated a grade and
received special education. They differed significantly from non-ARND
children on standardized measures of intelligence, language, and memory
abilities.

Interpretation
Statistical differences were not found on indices of attention and socioemotional
problems, however, both groups presented with clinically significant elevations
in these domains. Our findings suggest that future research will need
to clarify the extent to which such problems are unique to children with
ARND, particularly in contrast to other similar clinic-referred samples.

The first individuals diagnosed
with fetal alcohol syndrome in the 1970ís are now reaching adulthood,
yet there has been very little information available on adult outcome
in this disorder. This study presents the first neuropsychological data
on adults with FAS that has employed a carefully matched control group.
One of the most enduring findings in younger children with FAS is difficulty
with attention. Mirskyís model of attention provides a rich method for
assessing these deficits with attention. It is composed of three elements:
focus; sustain-vigilance; and shift. More recently a fourth element, encode,
was added to the model.

Methods
Subjects in this study, 17 young adults with FAS (mean age 21.4 years)
were compared to age, sex and IQ matched controls, who had no history
of teratogenic exposure.

Measures
Each subject completed an interview outlining their status and a battery
of neuropsychological tests. Only the results of the demographic and attention
measures are presented here. Attention was assessed using the Talland
Letter Cancellation Test (TLCT), a computerized version of the Continuous
Performance Test (CPT), the Wisconsin Card Sorting Task (WCST), and the
Arithmetic subtest of the Wechsler Adult Intelligence Scale-Revised. IQ
was assessed using the Wechsler Adult Intelligence Scale - Revised (WAIS-R).

Results
Intelligence: The mean IQ in the FAS group was 73.5. The mean IQ of the
matched controls was 73.1. Employment and living arrangements: FAS adults
were more likely to be living in the parental home than were controls.
Educational achievements: FAS adults had lower educational achievements
than controls. Attention: Adults with FAS had significantly more problems
with sustaining attention within tasks, with shifting attention across
tasks, and with encoding material into working memory, but did not differ
from controls in terms of focusing attention. Young adults with FAS do
appear to differ in subtle ways from other adults with developmental disabilities.

Maternal consumption of alcoholic
beverages during pregnancy can produce a broad spectrum of dose-dependent
toxic effects in the embryoñfetus, ranging from lethality or teratogenicity
(birth defects) for chronic, high-dose use of ethanol through to suppression
of fetal breathing-like movements for acute, low-dose use of ethanol.
Fetal alcohol syndrome (FAS) is a human manifestation of ethanol teratogenesis
(production of birth defects) that is diagnosed after birth during postnatal
life. The most debilitating feature of FAS appears to be structural damage
and functional changes of the developing brain that can have lifelong
adverse intellectual, neurological and behavioral consequences (ethanol
neurobehavioral teratogenesis).

Animal Investigations
Experimental animal investigations have demonstrated that one of the main
target sites of ethanol neurobehavioral teratogenesis is the hippocampus
of the developing brain. The hippocampus appears to play a major role
in the processes of learning and memory, and in behavioral regulation.
The mental deficiency and hyperactivity in patients with FAS may be due,
at least in part, to injury to the hippocampus produced by prenatal exposure
to ethanol.

Proposed Mechanism
In this study, a proposed mechanism for ethanol neurobehavioral teratogenesis
involving the hippocampus will be assessed. This proposed mechanism is
based on a signaling pathway that is involved in cell-to-cell communication
and utilizes glutamate, a neuroactive amino acid. Glutamate interacts
with a specific biochemical receptor molecule, the N-methyl-D-aspartate
(NMDA) receptor, which regulates the activity of an enzyme, nitric oxide
synthase (NOS) that synthesizes nitric oxide (NO), an important brain
messenger molecule. It is postulated that suppression of the glutamateñ
NMDA receptorñNOS signaling pathway in the fetus by chronic maternal consumption
of ethanol plays a key role in causing structural and functional changes
in the hippocampus. These changes manifest in postnatal life. This mechanism
is supported by our investigations in the guinea pig.

In view of the apparent time course
for loss of particular neurons in the hippocampus produced by chronic
prenatal ethanol exposure that manifests in early postnatal life, it is
proposed that therapeutic intervention, which targets the glutamateñNMDA
receptorñNOS pathway, may lessen the magnitude of hippocampal injury that
could manifest postnatally as adverse neurobehavioral changes. This research
is supported by the Canadian Institutes of Health Research.

Turner Syndrome is a sex chromosome
aneuploidy that occurs as a result of a nondisjunctional error in meiosis
I or anaphase lag; however, the etiology of this disorder remains unknown.
Anecdotal evidence suggests that paternal alcoholism may play an unidentified
role in the etiology of Turner syndrome (TS). Accordingly, the objectives
of this study were: (1) to determine the potential association between
paternal alcohol exposure and TS; and (2) to determine the potential association
between selected health and lifestyle behaviors of the parents and TS.

Method
This descriptive study employed a self-report survey methodology. The
questionnaire was designed to solicit information about the parentsí health
and lifestyle habits occurring one year prior to and throughout the pregnancy
of their daughter with TS. The primary outcome measure included in the
questionnaire was the Brief Michigan Alcohol Screening Test (BMAST). The
remainder of the questionnaire included questions about 5 other health
and lifestyle behaviors that were determined by clinical experts to be
relevant to the objectives of this study. (i.e. medical history, allergies
medications/drugs, nutrition smoking, alcohol consumption and environmental
hazards.)

The study population was solicited
from the Turnerís Syndrome Society of Canada and included any parent(s)
having a child with TS who was of any age. The children were not karyotyped
for this investigation, and hence this poses some limitation in interpreting
the findings.

The questionnaires were mailed to
245 families and 212 families completed and returned the survey. This
provided a response rate of 86.5%. Six of the fathers (3.6% n=166) and
six of the mothers (3.6% n=165) had scores of 5 or more on the BMAST (scores
of 5+ are considered to be in the "alcoholic range").This is considerably
lower than the population norm of 9.5%. An interesting finding suggested
that 54% of the fathers and 36% of the mothers reported that they had
been exposed to two or more environmental hazards.

Our study has not indicated that
there is a potential association between paternal or maternal alcohol
consumption and TS. However, we were surprised to learn that a previously
unidentified association between exposure to environmental hazards and
TS may exist. This hypothesis requires further investigation.

MOTHERISK SEEKS STUDY PARTICIPANTS

Asthma Medications In Pregnancy Project
Motherisk is currently collaborating
on a study to investigate the effects of asthma and its treatment on pregnancy
outcome. Eligible subjects include women, less than 20 weeks pregnant,
who are diagnosed with asthma which requires treatment. Healthy women,
less than 20 weeks pregnant, who are not on any chronic therapies and
not exposed to any teratogenic drugs qualify as controls. Participation
will involve 3-4 telephone interviews with the mother during pregnancy
and 1 after delivery. Participants will also be asked to consent to the
release of their medical records pertaining to delivery and infant's health.

Rheumatoid Arthritis & Arava (Leflunomide)In
Pregnancy Study
Motherisk is also collaborating on a study to investigate the effects
of Arava (leflunomide) on pregnancy outcome. Any woman treated for rheumatoid
arthritis who has taken leflunomide or other medications and who is less
than 20 weeks pregnant, can participate. Women will be interviewed by
phone 2-3 times in the pregnancy and again after delivery. In addition,
the child will be examined by a pediatrician after birth. For information
about these Motherisk studies please contact Dr. Costei at 416-814-7654
ext 4467 or speak to a Motherisk counsellor (416-813-6780).

BREAKING
THE CYCLE - INTEGRATED SERVICES FOR PREGNANT AND PARENTING WOMEN AND THEIR
CHILDREN

Since 1995 Breaking the Cycle (BTC)
has helped women who are pregnant and/or parenting children under 6 years
of age, and are struggling with problems related to alcohol and substance
use. But what makes BTC truly unique is that it also helps their young
children whose physical and psychosocial health and well-being are at
risk because of their exposure to alcohol and drugs.

Through the efforts of six partner
agencies - Mothercraft, Jean Tweed Centre, Motherisk, Childrenís Aid Society
of Toronto, Catholic Childrenís Aid Society, Toronto Department of Public
Health, and with funding from Health Canadaís Community Action Program
for Children (CAPC), this single access, community-based model provides
a wide range of adult and child services at one site in downtown Toronto.

An awareness education and outreach
strategy engages women in the earliest stages of their pregnancy, to reduce
the biological, psychosocial and cumulative risks of alcohol and drug
use to the fetus and provide prenatal care and birth planning support.
With time and acceptance, even the most high-risk woman can be engaged
in a process of planning for her infant.

The BTC Target Population
BTC has provided services to almost 500 families. An average of 100 new
families are admitted each year. Ninety-two (92%) of the women admitted
are parenting at admission; 25% are pregnant.

All of the BTC children are, or have
been, exposed to substances or substance-using environments. Forty-six
percent (46%) of BTC mothers have reported that their primary addition
is to crack cocaine, 34% have reported that their primary addiction is
to alcohol. The average length of their addiction is 11 years. Sixty-three
percent (63%) of BTC mothers have reported that they used their primary
drug of choice within the last 4 months prior to attending BTC. Many are
still using their drug of choice at admission to BTC.

Half (50%) of BTC women have reported
that they received the services of a child welfare agency when they were
children, indicating an inter-generational pattern of maltreatment. One
third of BTC mothers had at least one child in foster care at admission.
Approximately 90% of BTC families also receive the services of a child
welfare agency. Almost 75% of BTC mothers are single, separated, divorced
or widowed and are parenting an average of 2 children each. Eighty-five
percent (85%) of BTC mothers have report that their annual income is less
than $14,999, with 43% reporting that their income is less than $9,999
per year. Twenty-four percent (24%) of BTC mothers report that they have
no fixed address, and/or are living in transient or sub-standard housing
situations.

Sixty-seven percent (67%) of BTC
mothers have reported a history of sexual abuse, 80% reported a history
of physical abuse and 83% reported a history of emotional abuse. Forty-two
percent (42%) of BTC women have reported that they had attempted suicide,
with an average of 2.5 attempts. Twenty-seven percent (27%) have reported
that they had engaged in self-harm behaviors. Two-thirds (66%) reported
a family history of substance use, indicating an inter-generational cycle
of substance use. These data confirm that BTC is reaching and engaging
a very high-risk and marginalized population of women and children. They
are also the first Canadian data that describe the characteristics and
needs of this vulnerable population in a Canadian context.

Child Health And Functioning
Approximately 25% of the women at BTC are pregnant at admission. The children
born after their families were admitted to BTC had fewer birth complications
and decreased postnatal diagnoses than those of the same mothers who were
born before their families were admitted to BTC. In addition, BTC-born
children had better maternal health ratings, fewer health concerns, fewer
separations from their mothers and mothers had fewer developmental concerns
about their children.

Developmental ratings of BTC-born
children showed significant improvement over a six-month period in which
the family was involved in the program. The developmental lag, which is
often reported in the research on substance-exposed children, did not
materialize.

Parenting Skills
Pre-and post measures of maternal stress, dysfunction and distress indicated
that over a six-month period in which they attended BTC, mothers experienced
less parental distress, less dysfunctional parent-child interactions,
and less stress due to a difficult child. These measures were gathered
using a semi-structured interview that was created for program evaluation
by Boyle and Offord (1995). Mothers also reported less use of harsh discipline,
more mother-child activities, and increased positive feelings about parenting
since attending BTC.

Maternal Health And Substance
Use
Women who attend BTC access health and counselling services to meet their
own needs and the needs of the child(ren). At this time, the results of
measures to evaluate maternal substance use are inconclusive. However,
both BTC staff and client focus groups reported that many mothers have
been able to make significant and difficult changes in their substance-using
lifestyles and are on the road to improved maternal health.

The continuing challenge is effective
outreach and client engagement. That is why BTC conducted a recent study
entitled Drug Addiction & Pregnant/Parenting Women: Factors Affecting
Client Engagement. An important finding was that women who present for
service at BTC while pregnant are significantly more likely to be homeless,
use crack cocaine as their drug of choice, and have attained a lower level
of education than non-pregnant women. These factors were identified as
significant barriers to engagement of pregnant, substance-using women
in programs, and to treatment maintenance.

This population of homeless, pregnant
women represents a higher-risk sub-population of drug-using women whose
barriers to health and effective treatment are even greater than within
the larger population of substance-using pregnant or parenting women.
BTC has therefore launched a pilot project to reach these women through
street-based agencies in Toronto that serve homeless women. Agency staff
have responded enthusiastically, helping to refer pregnant women to withdrawal
management services, medical care, prenatal support services, and BTC.
Additional homeless pregnant women have also been identified through women
attending these street-based agency programs.

BTC/Motherisk Community-Based
FAS Diagnostic Clinic
Another important initiative is the BTC/Motherisk community-based FAS
Diagnostic Clinic at Breaking the Cycle. This Clinic will extend the expertise
of the Motherisk FAS Clinic to the community. Motheriskís medical/diagnostic
expertise will complement the history-taking and developmental assessments
that currently take place at BTC, and will complete the assessment and
possible diagnosis of children who are affected by their motherís prenatal
alcohol use.

Early diagnosis of children who are
effected will help ensure appropriate programming, education and support
to children and families in the preschool and school years, and may prevent
the development of many of the secondary disabilities associated with
prenatal alcohol exposure. Families and children will receive comprehensive
pre-diagnostic and post-diagnostic supports as they undergo this assessment
process. For more information about this or other BTC services please
call (416) 364-7373.

Margaret Leslie,BTC Program Manager

The Alcohol and Substance Use Helpline is sponsored by the Brewers Association of Canada.

This issue of the Motherisk Newsletter is supported by the Brewers Association of Canada.

ABOUT MOTHERISK

Motherisk counselors talk to hundreds of women and their healthcare providers each day providing guidance, support and peace of mind. So if
you don't find the information you are looking for on this website, try calling one of our Helplines. Motherisk counselors are available Monday through Friday, from 9
a.m. to 5 p.m. EST.

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The information on this website is not intended as a substitute for the advice and care of your doctor or other health-care provider. Always
consult your doctor if you have any questions about exposures during pregnancy and before you take any medications.

The Hospital for Sick Children (SickKids) is a health-care, teaching and research centre
dedicated exclusively to
children;
affiliated with the University of Toronto. For general inquires please call: 416-813-1500.